SF Smith, School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, CB2 0SP, United Kingdom

Abstract

Introduction: Coronary artery disease (CAD) is the accumulation of atherosclerotic plaque in the coronary arteries; resulting in limited myocardial perfusion. CAD has high levels of global morbidity and mortality and is well researched. Asymptomatic coronary artery disease (ACAD) is the precursor subclinical state and is inadequately detected and researched. The aim of this article was to cross-examine the current research on ACAD. Emphasis was placed on methods of assessment and screening of ACAD.

Materials and Methods: A review of the literature was completed following a structured protocol; search engines, inclusion and exclusion criteria were defined a priori.

Results: Forty-eight articles met all inclusion criteria and were retrieved for detailed analysis. Outcome-based evidence suggested that cardiovascular disease risk stratification followed by imaging based assessments in low-to-moderate risk candidates were shown to be of clinical value in ACAD. A ‘treat all’ primary preventative approach was shown to be of most benefit; however the social and financial implications of this remain unclear.

Conclusions: Effective management of ACAD is essential to lower the worldwide incidence, morbidity and mortality of CAD. Further outcome-based evidence highlighting the benefits of identification, screening and early primary prevention of ACAD is urgently needed.

We are pleased to be able to publish the abstracts from the 6th Annual National ATRIUM Conference, which took place on 22nd February 2014 at the Chancellor’s Building, New Royal Infirmary of Edinburgh. This annual conference is organised by ATRIUM, a student-run organisation at the University of Edinburgh which aims to encourage research amongst undergraduate medical students. Their website is http://www.atriumsoc.co.uk/

There were a mixture of oral and poster presentations, which are listed below. The name of the presenting student is in bold.

Oral presentations

In 1979, Nobel laureate Francis Crick published a paper discussing progress in neuroscience. Describing the subject as “profoundly mysterious”, he speculated on new methods of investigating the brain, including the ability to inactivate one type of neuron whilst leaving the others “more or less unaltered” [1]. Crick is not alone; for years the mammalian brain has dumbfounded researchers [1,2]. In the human, a hundred billion neuronal parts and myriad connections lead to an interconnected system of a level of unparalleled complexity [3].

The World Health Organization estimates that neurological disorders currently affect one billion people worldwide, a number which is predicted to increase considerably as a result of an ageing population. The need to further understand the brain and make progress in the field of neurology has therefore never been greater. However, with over 100 million neurons each making over 1000 synapses, the human brain is undoubtedly the most complex organ in the human body, and it is this complexity that has meant that advances in neuroscience have been comparatively slow.

It is our pleasure to once again be able to publish the abstracts for posters presented at the recent CamSurg conference, which took place on Saturday 22nd February, 2014, at Addenbrooke's Hospital in Cambridge. Following on from the successful 2013 conference, CamSurg organised an interesting mix of keynote speakers, workshops and oral and poster presentations. The full programme can be found on the CamSurg website http://www.camsurg.co.uk/CamSurg/#

The following abstracts were put forward for presentation at the conference:

At some point within your medical training, whether it’s during your first Obstetrics attachment or if you venture to the Radiology department, you are likely to encounter the use of Obstetric ultrasound scanning. However, it can be a complex subject to master and is not covered extensively in the undergraduate core curriculum or textbooks. This article discusses the key essentials that will help you make the most of your learning experience in these situations.

Abstract

Patients diagnosed with Coeliac disease are known to be at higher risk of suffering a low-impact fracture, and even as children it is important to detect and correct malabsorption due to Coeliac since this may have a lasting impact on their lifelong fracture risk. The British Society of Gastroenterologists recommends that those Coeliac patients with two or more additional risk factors for osteoporotic fracture undergo a dual X-ray absorptiometry (DEXA) scan to determine their bone density. This audit addressed the question of whether this standard was being adhered to in a general practice setting in the south-east of England. The capture of cases represented a prevalence of 1:275 (similar to previously reported figures for the prevalence of this condition). The rate of DEXA scanning in this population was disappointingly low (only 37%), and since many of those Coeliac patients who should have been scanned, and were not, possessed ‘minor’ risk factors such as smoking or female gender, the low pick-up rate may be attributable to a lack of awareness of the small but significant risk that these factors pose. Of those DEXA scans performed, the bone mineral densities of the patients concerned was inversely proportional to the number of risk factors they possessed, supporting the stance of the BSG. Practitioner education alone was not sufficient to improve the rate of scanning, which actually declined following a period of raising awareness of the need for such scans.

Introduction

Phèdre is a tragedy which explores the relationship between moral culpability and responsibility for one’s actions by examining the incestuous love of a queen for her step-son, a passion that is apparently imputed to her by a vengeful deity. What is fascinating for the purposes of our discussion is the dynamic interplay between the portrayals of Phèdre’s infatuation both as an illness and simultaneously as a crime, for this is essentially the same question we must consider in deciding to what extent a malady excuses behaviour that contravenes society’s judicial expectations. While this was doubtless an intriguing consideration for a seventeenth century French dramatist, it is all the more pertinent for us today given the extent of medicalisation that has occurred in recent decades across many spheres of society. In terms of psychiatry, this may be illustrated merely with reference to the DSM, which between its first edition in 1952 and the fourth revision fifty-two years later has more than tripled the number of conditions it identifies, taking the total from 112 to more than 370 today [1]. This inexorable rise has led certain commentators to question the extent to which this phenomenon is justified, particularly where it impinges on the realm of moral accountability. This is exemplified in an article by the sociologist Frank Furedi entitled The seven deadly personality disorders, in which he describes how all of those vices that the Catholic Church once taught to be mortal sins are now considered by Western culture to be addictive illnesses, with the sole exception of pride, which is thought to be a virtue, the helpful antidote to low self-esteem [2]. This issue is one of eminent importance to the forensic psychiatrist, who may be obliged to stand as an expert witness and give evidence on a defendant’s mental state, potentially obviating the accusation that they had the mens rea for a crime. This is particularly the case in homicide, where mental illness can reduce a verdict from murder to manslaughter, but it is of more general significance in the verdict of ‘not guilty by reason of insanity’. Thus, this essay shall concern itself with a consideration of the current theories on which medico-legal practice seems to be predicated, before examining a possible alternative to this model and the congruence of this with a broader philosophical perspective, concluding with some speculation as to the implications of this concept for clinical practice and for society.

Clinical History

A 14 year old girl was seen in clinic after an injury whilst playing rugby. Although her description was vague, she intimated that a valgus stress had been put on her left leg and described being tackled in rugby practice. She fell on her left knee and heard an audible cracking or ‘pop’ sound, experiencing immediate pain and swelling of the joint. She had no significant past medical history and was taking no regular medication.

Abstract

This paper attempts four things:
(1) to identify uncertainties and ambiguities in English law and medical guidance concerning the circumstances in which a competent adolescent patient who refuses a clinically indicated treatment can be overruled by a court of law in their own best interests;
(2) to clarify the nature and sources of two opposing attitudes towards the matter of the extent and limits of an adolescent patient’s right to refuse clinically indicated treatment;
(3) to argue for the need to set up in hospitals a Liaison and Mediation Service to facilitate communication between an adolescent who refuses treatment and their doctors with a view to developing, if possible, an agreed decision; and
(4) to outline a widened conception of an adolescent’s best interests which includes, besides the restoration of their health, respect for their personality and autonomy, acknowledgement of their right to be informed about the treatment proposed to them, recognition of their capacity to gain considerable understanding of the nature and consequences of the treatment and any alternatives, and also acceptance by doctors and judges of their ability to make their own decisions which is commensurate to the degree of intellectual and emotional maturity they have attained.